Myomata Uteri (Fibroid Tumors)
The uterus is a hollow ball of muscle. Tumors of the muscle wall of the uterus are the most common benign tumors of the female pelvis.
The official term for these tumors is “myoma.” However, they are popularly called “fibroids” for reasons that are probably lost in antiquity.
Despite their common occurrence, surprisingly little scientific research has been done. No one knows exactly how common they are. There is however, “the rule of 40”. With careful ultrasound evaluation, at least 40% of women who reach the age of 40 will have at least one small fibroid in their uterus.
Fibroids are in fact common in women of all races. They are more common in African-American women, most likely on a genetic basis. There is also good data that shows that African-American women who have a history of childhood sexual abuse are more likely to have symptomatic fibroids. The study was done specifically in African-American women so there is no information available at this time as to whether the same would apply to women of other racial groups. I’m not sure of the mechanism but the data is there.
Despite their frequency and despite the fact that fibroids cause a great deal of mischief for women, and despite the fact that they account for a rather substantial amount of health care expenditure, there is surprisingly little scientific data concerning the best way to treat fibroids although that is slowly changing.
There are approximately 500,000 hysterectomies performed in the Unites States each year. Most of the studies would indicate that at least a third of those hysterectomies are related to fibroids in one way or another.
For women desiring preservation of their uterus, myomectomy was the treatment of choice. Approximately 40,000 myomectomies are performed each year in this country. However, as more data becomes available, it appears that Uterine Artery Embolization is the better procedure for women who wish to keep their uterus, for whatever reason.
Yet, despite the frequency with which fibroids cause women to seek health care, the treatment more often depends upon the personal experience and bias of the physician treating a given woman than any real scientific data to support one therapy over another.
Fibroids are frequently found in women who are either trying to become pregnant or who suffer repeated pregnancy losses. One would think that in this particular situation, there would be a great deal of data to help guide a physician as to the best choice of therapy. In fact, again, there is very little. Hardly a year goes by when I do not either hear of or see a debate between “authorities” as to how fibroids should best be managed.
Sometimes it is in fact a “no brainer”. If a woman is having significant symptoms such as bleeding or repetitive pregnancy loss and she has a fibroid that is inside her uterine cavity, almost no one would debate the need to remove that fibroid. Such women, however, are relatively uncommon. Most women’s fibroids are simply within the wall of the uterus and it is not always so clear cut as to what the best approach should be.
We do know that the tumors are estrogen sensitive. Therefore, drugs (the GnRH agonists such as Lupron or Synarel) that create an artificial menopause and lower estrogen levels will cause the fibroids to shrink. Natural menopause will also accomplish the same thing. However, giving Hormone Replacement Therapy after menopause does not usually cause the fibroids to grow to any significant degree.
There does seem to be an inherited tendency to develop fibroids. There is some evidence that women inherit an increased susceptibility to estrogen stimulation of the fibroids. The mechanism for this seems to be an increased concentration of estrogen receptors in the fibroids and this increased concentration is what is inherited.
Malignancy in a fibroid is rare. Contrary to popular belief, a rapid increase in the size of a fibroid does not usually mean malignancy. Therefore, the treatment of a fibroid usually depends upon the symptoms it is producing. Depending upon their size and location, fibroids may cause irregular bleeding; they may cause pelvic pressure and discomfort (though actual pain is rare); or they may effect a woman’s ability to either become pregnant or may cause her to lose pregnancies repetitively.
Many women with fibroids and pelvic pain come to me having been told that the fibroids were the cause of their pain. This is not true.
Fibroids are like real estate — location, location, location. A small fibroid inside the uterus will cause more problems that a large one on the outside.
The mere presence of fibroid tumors of the uterus is not sufficient indication for therapy — neither is their size. They must be producing symptoms or an infertility problem.
The only definitive treatment for fibroids is surgical removal. Depending upon the age of the woman and her desire for future pregnancies, such surgery may be either a hysterectomy or a myomectomy. A myomectomy removes the fibroid tumor while preserving the uterus.
These surgeries can either be done through a full abdominal incision or by laparoscopy, depending on a number of factors such as the size and location of the fibroids. If a myomectomy is being done for infertility, it is best done through a laparoscope. Advances in medical technology now allow the uterine wall to be closed in a manner that is as good as if it were done through a full incision.
There are drugs (the GnRH agonists) that will reduce the size of the fibroids by approximately 30%. However, the fibroids regain their previous size within several months after discontinuing these drugs. They are not usually considered to be a long term treatment, but can be in certain circumstances. They are however, of great value in the preoperative preparation of a patient for surgical correction. In fact, I believe that unless it is an unusual situation , no woman should undergo surgery without pre-op Lupron therapy.
At one time, medical practice dictated that a hysterectomy was warranted once the uterus reached a certain size (the size of a 12 week pregnant uterus). We now know that this is not a valid reason for therapy. However, I can understand the rationale for it based on the lack of accurate diagnostic tools. The mere fact that the fibroids have grown is not an indication for surgical removal - they must be producing symptoms. The one exception to this is a fibroid that is rapidly increasing in size. This may indicate a malignancy and is an indication for surgery. Such a scenario is uncommon. Again, it is usually not a sign of malignancy but could be.
A number of articles and books have suggested that women should not have a hysterectomy - only a myomectomy. These articles create the misconception that a myomectomy is somehow a simple and easy operation compared to hysterectomy. In fact, a myomectomy is every bit as much surgery as a hysterectomy (and often more so) with all the risks and complications of a hysterectomy and it requires the same degree of recuperation. In fact, women undergoing a myomectomy often lose more blood during the surgery than women having a hysterectomy. It is often more difficult to perform a myomectomy than a hysterectomy.
Furthermore, 25 to 40% of women who undergo a myomectomy will, at some time in the future, require another operation for their fibroids. The likelihood of your fibroids recurring depends upon how many you had at the time of your myomectomy. Women who have one large solitary fibroid have a much lower chance of developing another one in the future. However, women who have had multiple fibroids in their uterus are the ones who are much more likely to develop new ones in the future. Women who wish to preserve their uterus with a myomectomy must be aware of these facts. A myomectomy is major surgery. It is a valid alternative to hysterectomy but a woman should never opt for a myomectomy in the naive belief that it is simpler, easier, and safer.
Another problem with myomectomy, especially if it is done through a full incision, is the fact that it usually creates massive pelvic adhesions which can seriously interfere with the woman’s ability to become pregnant and which can also cause severe pelvic pain.
Laparoscopic myomectomy is still a relatively new operation and therefore, good data is not available as to how much adhesion formation results from this approach.
Newer therapies are emerging that may permit the treatment of fibroids either by laparoscopy or radiological techniques. A laparoscopic technique involves the use of a cryo-probe which freezes the fibroids and destroys them. However, there is no definitive data that such an approach is better than existing techniques.
Fibroids inside the uterus may sometimes be treated by hysteroscopy depending on their size and location.
LAPAROSCOPICALLY ASSISTED MYOMECTOMY
Until relatively recently, if it was determined that a woman would be best served by a myomectomy, that surgery was always done “open” - in other words with a large abdominal incision. Not only is this significant major surgery to go through (there is an increased need for blood transfusion), pelvic adhesions following a myomectomy are a major problem. Many women will undergo a myomectomy to correct a fertility problem and then find themselves unable to become pregnant afterwards because of the severe adhesions that developed from the surgery itself.
The advent of the techniques of minimally invasive surgery now permit me to carry out a myomectomy with the aid of a laparoscope. The initial portion of the surgery is done laparoscopically. This allows the myomectomy to be done through a much smaller incision than would have formerly been possible. In some instances, the woman is actually able to go home the day of her surgery.
Not everyone is a candidate for a Laparoscopically Assisted Myomectomy. If the uterus is very large, it is simply not technically feasible to do it. Nonetheless, this is a valuable technique for those women who are candidates for it.
Another advantage of minimally invasive surgery is the fact that fewer (but not “no”) adhesions will form after the surgery. If a woman has undergone the myomectomy as part of a fertility treatment, there is a smaller likelihood that her fertility will be compromised as a result of the surgery itself.
Another advantage of a Laparoscopically Assisted Myomectomy is that it permits a better and more secure closure of the uterine wall. This is especially important for the woman undergoing a myomectomy for reasons of fertility. Given today’s technology, it is not possible to close a uterine wall well enough through a laparoscope to allow it to hold together during a future pregnancy. This problem is eliminated with the laparoscopically assisted approach.
There is available a drug therapy that may also help women with symptomatic fibroids. This involves the use of the GnRH agonists (Synarel or Lupron).
To a considerable degree, fibroids are estrogen dependent. As a result, if ovarian function is suppressed and estrogen production is lowered, not only will the fibroids stop growing, they will actually shrink. The drugs that accomplish this are called the GnRH agonists. Synarel is a nasal spray. Lupron is a once a month injection.
The GnRH agonists are very useful in helping prepare the uterus for women who are going to undergo a surgical procedure, especially a myomectomy. Treating a woman with these drugs for several months prior to myomectomy makes the surgery easier.
Occasionally, however, these drugs can be used as the sole treatment for the fibroids. This is especially true for the woman who is close to menopause. If the symptoms that her fibroids are producing can be controlled for a year or two and she then goes into menopause naturally, she can avoid a surgical procedure.
It is important to understand that the beneficial effects of the GnRH agonists last only as long as you take the medication. If you stop the drug, the fibroids will regrow to their pre-treatment size within a few months. Therefore, it is usually not a practical therapy for a woman in her thirties or early/mid forties as she would have to be on these drugs for many years. However, for a woman in her late forties for whom it is anticipated that she would go through menopause within the near future, the use of these drugs can often be very effective and allow her to avoid a hysterectomy.
UTERINE ARTERY EMBOLIZATION
Until relatively recently, the only two options for women with significant myomata were either myomectomy or hysterectomy. There are now two other options - GnRH suppression as discussed in the previous section and Uterine Artery Embolization.
Uterine Artery Embolization (UAE) is a procedure that has been around for many years. It was originally employed as an emergency technique to stop severe bleeding either following a delivery or other pelvic surgical procedures. Over the past ten years, it has become more increasingly used as an elective procedure to treat symptomatic myomata.
You may also see UAE called “UFE” – Uterine Fibroid Embolization. The 2 terms are synonymous.
The principle underlying the usefulness of UAE is based on the fact that while the uterus in general has a very complex blood supply, only a single artery supplies a single fibroid. As a result, if you can plug off that artery, the fibroid will die.
UAE involves a technique that is virtually identical to the procedure used for cardiac catheterization. If you were to undergo UAE, you would be awake but sedated. A catheter is inserted into the large artery in your groin using local anesthesia. These catheters are then passed through your arteries and, in the hands of a skilled radiologist, the uterine artery is identified and then the catheter passed into it.
Once the catheter is in place, almost microscopic beads are injected. These beads will then plug off the artery supplying the fibroid and the fibroid subsequently dies.
As I have said, even though other arteries in the uterus will also be plugged off, because of the complex linkage of the various arteries within the uterine wall, the uterus as a whole does not appear to suffer any serious consequence — unless seriously challenged as in a pregnancy.
Until a few years ago, UAE was considered experimental. To be sure, we still do not have the extensive experience with it that we have with myomectomy or hysterectomy. However, it is a procedure that is being used with increasing frequency and more recent data indicates that it is a safe and effective procedure.
As with any medical procedure, UAE has its associated problems. Most women who undergo the procedure will spend one night in the hospital. There can be a fairly significant amount of pain following the procedure. This pain usually will disappear within a week to ten days. Many women will also run a fever for the first week or so following the procedure.
Serious complications are apparently uncommon. A few deaths have been reported. So far, the numbers do not appear to be unusually different than what might be expected from other procedures such as a hysterectomy.
Some women will experience severe bleeding to the point where emergency hysterectomy is necessary.
Some women will actually pass a fibroid through the vagina after it has died. Overall, however, if women are properly selected, most will have a very good result from this procedure.
UAE VS. HYSTERECTOMY
Whenever a new drug or technique or technology is developed, everyone jumps on the bandwagon. In the beginning, these new developments are looked upon as the greatest thing since sliced bread. A year or two later, they are dismissed as being worthless. Finally, they find their proper niche as we recognize that everything has its benefits and everything has its risks.
The same is true for Uterine Artery Embolization. In the beginning, it was greeted with some skepticism. However, around five years ago, it became the “treatment of choice” for women with symptomatic fibroids. Now, however, with the passage of time and the accumulation of data, it is finding its proper place in our therapeutic armamentarium.
In 2007, the results of a randomized study were published. Women with symptomatic fibroids were allocated to either a hysterectomy group or a UAE group. They were then evaluated up to a year later to try to determine which is the better treatment.
The results were a little surprising. Although in the short-term women in the UAE group did better, in the long run, the hysterectomy group came out ahead.
Initially, women going through UAE appear to do better because it is a somewhat simpler procedure, it is either done as an outpatient or perhaps one night in the hospital, and recuperation is rather quick. Contrast this to hysterectomy which, especially for large fibroids, requires open surgery, several days in the hospital, and 6 to 8 weeks of recuperation.
However, what many people have failed to take into consideration is the fact that if you undergo UAE, your uterus is still there. It may continue to cause problems. As a result, a number of women will have to undergo a repeat embolization and still others will ultimately end up with a hysterectomy.
A study published in early 2008 showed that within 3 years after UAE, almost 10% of women had undergone a hysterectomy. This also needs to be factored into the decision making process.
It appears from the results of this study that overall patient satisfaction was greater in the hysterectomy group than it was in the UAE group. However, this difference only shows up over time.
One of the worse things a physician can do is treat his or her patients based upon their own limited personal experience. This is why we rely on large studies with numerous patients and numerous physicians to give us a more balanced view. Nonetheless, I can tell you that most of my patients who have undergone UAE have been extremely pleased with the results. I have had a few patients who have undergone embolization and who subsequently required hysterectomy because the embolization did not satisfactorily corrects her problems. However, I still continue to believe that, all other things being equal, a woman is probably better off with UAE as an initial approach recognizing that nothing in medicine comes with a written guarantee and that a hysterectomy may have to be done in the future.
UAE and ADVERTISEMENTS
I want you to be aware that physicians who perform UAE often advertise their services in various popular magazines. I came across one such advertisement that promoted UAE as a safe alternative to hysterectomy. Furthermore, the advertisement also suggested that it was an appropriate procedure for women with fertility problems related to their fibroids. However, the official guidelines specifically state that UAE should not be done in a woman contemplating a future pregnancy.
I would caution you that neither of these statements is supported by our current level of information. Although complications from UAE appear to be low, they are also low with hysterectomy. As I have pointed out, women have died from UAE, although not frequently.
At one time, for women who are interested in future fertility, uterine artery embolization was contraindicated. As more and more studies are coming out indicating that it is not as deleterious to fertility as we had once believed, our thinking is changing.
Perhaps most importantly, current data indicates that the only fibroids that interfere with fertility are those that are within (partially or totally) the uterine cavity. These are best treated by hysteroscopic resection. Fibroids that are in the uterine wall up against the uterine cavity may also affect fertility but the data is not as good. The bottom line — treating large fibroids by either UAE or myomectomy in a woman who is trying to have a baby is rarely necessary.
I point this out because I believe that this is symptomatic of the type of problems one can get into when the physicians who perform UAE (Interventional Radiologists) are not gynecologists and, therefore, were not trained to look at every aspect of the problem they are treating. Furthermore, as I have pointed out, all they do is the UAE. Any problems afterwards are handled by Gynecologists. Not having to deal with complications does tend to put a different perspective on things.
UTERINE ARTERY LIGATION
Another option which has recently been developed for the treatment of myomata uteri is a laparoscopic uterine artery ligation. The purpose of the uterine artery ligation is the same as uterine artery embolization. It is designed to cut off the blood supply to the fibroids.
Uterine artery ligation is a relatively new procedure. Preliminary reports indicate that it is as successful as UAE. It probably is successful because, as I have already mentioned, each fibroid is fed by a single artery whereas the uterine wall itself has a very intricate blood supply. This makes the fibroid much more susceptible to any compromise in its blood supply whereas the rest of the uterine wall is able to survive. In fact, studies have been done that clearly show that within 6 to 8 hours after uterine artery ligation, much of the uninvolved muscle wall of the uterus has regained a significant part of its blood supply.
It must be understood that this is a new procedure and, although the initial reports are promising, it will take a while before we have fully determined its place in our armamentarium. Therefore, the same sort of concerns must apply. Women considering future childbearing and women under the age of 40 should probably not undergo this procedure until more information is obtained.
In addition, this is a procedure that should only be carried out by skilled laparoscopic surgeons - physicians who are used to working in difficult areas of the pelvis. Nonetheless, it has the advantage of being performed by Reproductive Endocrinologists or Gynecologists who are used to evaluating women with myomata from every perspective. Although interventional radiologists are quite adept at the UAE procedure, they do not always fully understand the pros and cons of such a procedure and who might be better served by an alternative.
I am also convinced that another reason for developing the uterine artery ligation is so that the gynecologist is in charge of the entire process from beginning to end. If an interventional radiologist carries out a UAE and there are significant complications, it is the gynecologist who must be called in to deal with those complications. Speaking from personal experience, that is not a position that I would like to be put in. Unless I had specifically referred the patient for the procedure, neither I nor any other physician likes to be called in to treat a problem that another physician has created, especially when it was done without my involvement from the very beginning. This type of situation would be compounded if I did not agree with the UAE and the indications for its use.
A new therapy for the treatment of myomata was introduced in late 2004. It is FDA approved and it uses an MRI to identify the myomata coupled with targeted high frequency ultrasound to destroy the myoma.
It seems like a great idea - it’s non invasive. It is, however, brand new so no one really knows what the long-term risks and benefits are - give us five years and we will let you know.
The other main issue is the fact that many insurance companies still consider this experimental even though it is FDA approved (don’t you just love them).
The other issue is that radiologists don’t want to do them. From what I’ve been told, it takes a very long time. You have to lie on the table for several hours while the MRI identifies all the myomata and then they have to guide the ultrasound to take care of it. A radiologist could do three or four other procedures in the same amount of time that it takes them to do one targeted ultrasound for myomata. In today’s world of managed care, it is simply not cost effective for the radiologist to do this type of procedure. It sounds very nice in theory - it may never really achieve true practical significance.
There is a new class of drugs coming along called Selective Progesterone Receptor Modulators. These drugs affect the way progesterone interacts with its various target tissues and they should be on the market probably in 2006 or maybe 2007. Initial reports indicate that they are quite effective in the medical therapy of myomata.
We have known for many years that estrogen stimulates the growth of myomata. We never had much evidence that progesterone itself was a major influence. Why these particular drugs should work is still not fully understood but, nonetheless, they do and, once they are finally FDA approved, they will offer us one more tool to use in the treatment of myomata. It will be a non-surgical approach and, as the evidence is mounting, we are beginning to learn that, except in very selective instances, the surgical treatment of myomata will probably be relegated to the history books in the not too distant future.
My advice for women with fibroids is as follows. First of all, understand that before you undergo any treatment for any problem, you must complete the following sentence: “After …., I will be better off because –”. If you cannot complete this appropriately, then the therapy is not justified and I do not care what it is.
It is important to understand that the mere presence of fibroids is not sufficient indication to treat them. They must be causing symptoms.
If you are not interested in fertility and are over the age of 40, UAE is the treatment of choice. As time goes by, hysterectomy will become less and less frequent, especially for fibroids.
When uterine artery embolization was still considered “experimental” and until we got sufficient experience with it, it was considered to be contraindicated in women interested in having children in the future. However, as of 2013, there are a number of studies that clearly show that our concerns about the effect of embolization on fertility were not really justified. There are now numerous reports of women having successful pregnancies after embolization. Therefore, women with significant fibroids who are desirous of future fertility are as good a candidate for embolization as anyone else.
The SPRM’s have not yet been released. They may change everything. Only time will tell.
FIBROIDS AND FERTILITY
I want to discuss the whole subject of how fibroids and fertility interact because it is often confusing. Although I have mentioned and discussed fibroids several times in this pamphlet, I thought that putting it all in one section would help clear up any misunderstandings.
Although many women with fibroids do become pregnant on their own and had a successful pregnancy, there is also no question that for some women, fibroids will affect her fertility.
If the fibroids are projecting into the uterine cavity, everyone agrees that they should be removed since they definitely affect the woman’s ability to either become pregnant or to stay pregnant.
Fibroids that are compromising the uterine cavity are easily treated in today’s world by hysteroscopic resection and the results are usually very good.
The controversy arises when a woman has fibroids that are in the wall of the uterus but not affecting the uterine cavity. Sometimes these fibroids will compromise fertility and often they won’t. Data clearly shows that for women going through IVF, the success rate is low or if she has fibroids in the wall of the uterus even if they are not compromising the endometrial cavity.
If a woman has fibroids in the uterine wall and if she is not becoming pregnant or if she is becoming pregnant and having recurrent pregnancy loss, then consideration should be given to removing the fibroids.
If the fibroids are in such a position that they are at least partly on the surface or protruding from the surface of the uterus, they can be removed through a laparoscope. However, larger fibroids, especially if they are deep in the uterine wall, may require open surgery. The problem with this is that open surgery for fibroids (myomectomy) almost always produces severe pelvic adhesions. Those adhesions can significantly compromise the woman’s ability to become pregnant after that on her own.
If she is a woman who was going to undergo IVF anyway, then the adhesions don’t mean anything. However, if she is someone who was going to try to become pregnant by standard therapies other than IVF, she needs to be aware of what is going on and it needs to be fully discussed in terms of the surgery and its alternatives.
UPDATE – 2012
In the pamphlet, I discussed uterine artery embolization and discussed the previous evidence that if a woman had an embolization, she would go to an earlier menopause. More recent data indicates that this is either not a problem or much less of a problem than had been originally believed to be true.
Newer data also suggests that embolization can be safely used in women who are contemplating future pregnancy. This is not to say that the embolization might not affect the woman’s ability to become pregnant or stay pregnant. It simply means that again, our original concerns may not be as bad as the newer data suggests.
© Michael D. Birnbaum, M.D. 2013